Preparing the Next Generation of Clinical Investigators

When Alan I. Green, MD, was a young faculty member at Harvard Medical School in the early 1980s, committed to both practicing psychiatry and doing research, he often sought the counsel of one of his mentors, Joseph Schildkraut, MD, a physician-researcher in psychiatry.

“I would go to his office with an idea and he would say, ‘Okay; show me all of the steps that got you to your research question,’” recalls Green, chair of psychiatry at the Geisel School of Medicine at Dartmouth and director of SYNERGY, Dartmouth’s Clinical and Translational Science Institute. “It taught me that even though I may have been asking a reasonable question, I didn’t actually know how I got there.”

By learning how to think about and present his ideas in a clear and logical way, Green was acquiring some of the fundamental skills he would need to become a successful investigator.

“This is a really tricky business and it takes a long time to figure out how to get good at research,” he says. “In today’s highly competitive funding environment, young scientists not only need strong mentorship but resources and support from their home institutions to get off to a good start.”

That’s the idea behind Dartmouth SYNERGY Scholars, an ongoing mentored career development program at Geisel and Dartmouth-Hitchcock. Funded through SYNERGY—which is supported by a National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) secured by Green and his colleagues in 2013—the program aims to prepare junior investigators for careers in clinical and translational research.

The Scholars program offers a combination of didactic training, mentoring, exposure to multidisciplinary research, and ongoing evaluation. Importantly, it also covers 75 percent of Scholars’ salaries for two years and provides funds for research assistants, travel, supplies, and tuition.

On an early evening in April, Green is joined in his office by colleagues Martha Bruce, PhD, MPH, and Yolanda Sanchez, PhD, two senior scientists who serve as advisors for the Scholars program, as well as co-directors for SYNERGY education, training, and career development. They are there for a check-in meeting with 2016-18 Scholar Wilder Doucette, MD, PhD, an assistant professor of psychiatry.

Each Scholar, they explain, is matched with a primary mentor (among a team of mentors), for Doucette it’s Green, who supervise their training activities and patient-oriented research projects during their award period. The mentors chosen reflect the disciplines needed to gain independence in the proposed area of research.

“As advisors, we check in regularly with the Scholars and their mentors to see what has gone well so far, what the challenges are, and how we can assist them—whether it’s helping them design their research plans or navigate SYNERGY’s many resources,” says Bruce, a professor of psychiatry at Geisel and The Dartmouth Institute for Health Policy and Clinical Practice.

Interacting with people from different specialties helps you refine your thinking about your science and craft it in a more generalizable way, so you can get people outside your field excited about what you're doing."

-Wilder Doucette, MD, PhD

The program’s multi-faceted support is invaluable, says Doucette, who is about six months into his award period. “For example, I just finished taking the certificate course, which offered a structured introduction to translational medicine,” he explains. “The second part involved workshops with rotating faculty and with peers who are at a similar level of career development, which was also very useful.

“Interacting with people from different specialties helps you refine your thinking about your science and craft it in a more generalizable way,” he adds, “so you can get people outside your field excited about what you’re doing.”

This is critical when trying to secure large grants like R01s from the NIH, when only about 10 percent of applications succeed. “You have to be able to tell a compelling story about your research and its impact,” says Sanchez, an associate professor of molecular and systems biology at Geisel. “And you have to know where the remaining gaps are in your field and how your research is going to address them.”

Doucette’s research project is using a rat model to assess the effectiveness of neuromodulation—mild electrical stimulation of specific circuits within the brain—as a potential treatment for addiction, eating disorders, and obesity.

“Despite our best efforts in treatment and prevention, almost 40 percent of people in the US are overweight or obese, and the rates of obesity continue to rise,” says Doucette, who specializes in appetitive disorders and sees patients in an outpatient addiction clinic. “My primary motivation is to translate discoveries we make in the lab into alternative treatment tools that can be used to help patients.”

The two-year Scholars period is giving him protected time to build a critical mass of work, which includes compiling data, submitting manuscripts for publication, and securing pilot grants—“all things that people like me need to do to land larger sources of funding and become an independent researcher,” he explains.

The Scholars program also helps more established investigators develop skills in areas that are vital to advancing their careers. For 2014-16 Scholar Carrie Colla, PhD, a health care economist and associate professor of The Dartmouth Institute, that new area was qualitative research.

“My project involved using different data sources, including The National Survey of ACOs, Medicare claims data, and interviews with 16 Accountable Care Organizations (ACOs) who were participating in a Medicare-initiated payment reform effort,” she explains. “Basically, we wanted to know how the changes in payment incentives were affecting the care of patients who were transitioning from the hospital to post-acute care.”

Being a Scholar was a really special opportunity--the training will allow me to improve our grant proposals and strengthen my research in the future."

-Carrie Colla, PhD

Colla’s findings from her time as a SYNERGY Scholar have appeared in a number of papers, and have helped to inform the field about changes in post-acute patient care associated with ACO payment changes. “We are able to disseminate our research back to provider organizations who participate in either our qualitative interviews or our National Survey of ACOs through a distribution list, and share some innovative things that ACOs are doing to improve both the quality and efficiency of care,” she says.

“Being a Scholar was a really special opportunity—the training will allow me to improve our grant proposals and strengthen my research in the future,” adds Colla, who recently received a prestigious health policy fellowship from the Robert Wood Johnson Foundation.

Similarly, becoming a SYNERGY Scholar (2014-16) allowed Elisabeth Erekson, MD, MPH, to gain skills in health care delivery science. “It’s an aspect of research that I hadn’t explored before, which I was then able to tie back to what I do as a clinician—treat urinary incontinence and pelvic floor disorders,” explains Erekson, a practicing specialist in female pelvic medicine and reconstructive surgery at Dartmouth-Hitchcock, and an associate professor of obstetrics and gynecology and of The Dartmouth Institute.

My SYNERGY project provided the pilot data for an R01 grant from the NIH that was funded through Dartmouth and Brigham and Women's."

-Elisabeth Erekson, MD, MPH

In a collaborative project between Dartmouth and Brigham and Women’s Hospital, Erekson and her colleagues were able to successfully merge two separate data sources—a longitudinal survey known as the Nurses’ Health Study and Medicare claims—creating a powerful linkage that will provide new insights in how to improve care for older women with urinary incontinence.

“We have several abstracts being submitted and the papers will be coming out in about six months,” she says. “But even more exciting, my SYNERGY project provided the pilot data for an R01 grant from the NIH that was funded through Dartmouth and Brigham and Women’s.”

Leveraging Dartmouth’s emphasis on team science enabled Alex Gifford, MD, a pulmonologist at Dartmouth-Hitchcock and assistant professor of medicine at Geisel, to also form some fruitful external collaborations (among others) during his Scholars’ award period (2014-16).

“One of the things that the Scholar period enabled me to do, and this has been catalytic for my career, is to partner with regional academic medical centers to expand the scope of my research,” explains Gifford, who has focused his academic energies on performing clinical and translational research in the area of cystic fibrosis (CF).

One of the things that the Scholar period enabled me to do, and this has been catalytic for my career, is to partner with regional academic medical centers to expand the scope of my research."

-Alex Gifford, MD

Working closely with mentors George O’Toole, PhD, and Deborah Hogan, PhD, at Geisel’s department of Microbiology and Immunology, his project sought to determine if biomarkers of iron homeostasis could be used to customize CF care for patients who need to be hospitalized due to pulmonary exacerbations.

“The project went very well and we plan to publish our findings in the fall,” he says. “Being chosen as a SYNERGY Scholar came at a pivotal juncture in my career. It enabled me to successfully secure grants from the CF Foundation, which now help to fund my research, and cross the divide between intramural and extramural support.”

Strong mentorship, collaborative colleagues, protected time, and resources are all important contributors to a young investigator’s success. Another, which Scholar candidates themselves must possess in order to be chosen for the program, is tenacity or what some refer to as, “fire in the belly.”

To help ensure a high rate of success, Scholars are chosen by a multidisciplinary panel of senior scientists through a rigorous peer-review process. “Applicants have to put in a letter of interest, and only about half of those are accepted and asked to submit a full application,” explains Bruce, who along with Sanchez is a member of the review panel. “And then, depending on the year, only about 15 to 20 percent of applications are chosen.”

“Our review process is modeled after the NIH’s KL2 Scholars program,” says Sanchez, “where each award application is carefully reviewed and scored based on a number of criteria that are critical to determining whether a candidate has what it takes to succeed. We then rank the applications and make our recommendations to Dr. Green.”

Since 2011, there have been 16 SYNERGY Scholars (including the 2017-19 Scholar who will be announced soon) representing a diversity of departments and schools, and interconnected projects, across Geisel, Dartmouth-Hitchcock, and Dartmouth College.

“You know, when we wrote the grant for the CTSA, one of the things we noticed was that the number of young people coming into translational science at Dartmouth was relatively small, as was the number of career development awards,” recalls Green.

Their main goals, he says, have been to strengthen the infrastructure for clinical and translational research—to build a pipeline of investigators—and do it in a way that amplifies some of the strengths that Dartmouth already has, in areas such as basic science and outcomes research.

“I think we’re well on our way,” Green says. “One of the most important things that SYNERGY does, and the CTSA is making this all possible, is to develop young talent, those clinician-scientists and translational researchers that are going to be the future leaders and mentors here. They are the ones who will carry this important work forward and can have the biggest impact on population health in the future.”